Ruminations by a non-academic general surgeon from the heart of the rust belt.

Wednesday, February 4, 2009

Vaginal Nephrectomy

At Johns Hopkins last week, transplant surgeons removed a healthy kidney from donor Kimberly Johnson's vagina. And now the internet is abuzz with excitement. It's the new frontier! The natural extension of NOTES!

But several clarifications are needed. Number one, this wasn't really natural orifice surgery. The kidney was dissected and liberated through standard laparoscopic incisions. It was just extracted through the vagina. (And this is not something new anyway.) Instead of a small flank or periumbilical incision, (4-5cm), the kidney was placed in a sterile bag and brought out the vagina through a colpotomy. So the benefit (arguable at that) was one of cosmesis. Secondly, this patient went home the next day. Which is when most laparoscopic kidney donors go home anyway. Recovery is expected to be similar. More concerningly, the threat of bacterial contamination is introduced anytime you pass instruments/donor kidneys through the colonized mucosa of the vaginal vault. And remember, that kidney ends up getting implanted into an immunocompromised patient. So I guess I just don't get it. Why increase the complexity and risk of a completely elective operation when the benefits are chiefly cosmetic (and that's debatable at best)?

I've written about NOTES here and here. I admit I'm a bit biased at this point. Sometimes, in our drive to discover the 'next great thing', we forget about the highly efficacious modalities we already have. Laparoscopic cholecystectomy is an outpatient operation that's minimally invasive and allows patients to return to regular activities/work within a week or so. That's a tough standard to topple. And if we're planning on scrapping it, there better be a more compelling reason beyond the allure of "incisionless surgery" (and not really incisionless anyway) because the cost of the new equipment and the more onerous cost of training an entire generation of surgeons the new technique will be a tough pill to swallow, especially in these already strapped times.....

When I wrote about appendectomies through the mouth, one commenter (who was a surgeon) stated that "just because something CAN be done doesn't mean that it OUGHT TO be done." Think that comment applies to this case.

Thread jack! I hope you comment on Ruth B. G's case in your next post.

from the nytimes:"The surgery followed the discovery of a lesion during an annual check-up in late January at the National Institutes of Health in Bethesda, Md. A CAT scan revealed a small tumor, approximately one centimeter across, in the center of the pancreas, the court’s statement said."

in the med school so far they've told us they virtually only find these things when they are obstructing the CBD.

I felt incredibly up to speed watching tonight's ER. The crowd here at The Manor referenced your blog after I went "Oh, oh, oh! I know that!" at the first mention of NOTES.[Yes, I was that obnoxious student in elementary school.]

It was gratifying to see that the plot provided good justification for the procedure: a man in an iron lung (almost all day; post polio) needed an appendectomy --an abdominal incision would have impinged on his ability to breathe, as he used those muscles to control the process.

We were all thrilled not to have to deal with anything grabbed through the vagina. Major ick factor -- I am down with your concerns over bacteria. And whatever! It gives The Retired Educator the willies and Fred just thinks it's gratuitous. Moi, La Bonne et Belle Bianca? I think iatrogenic infection rates don't need any assistance!

The gang at Marlinspike Hall, deep, deep in the Tete de Hergé salutes you. Do we need to do any homework for next week's ER episode?

Bianca-If I understand you correctly, the patient in question had some sort of thoracic compliance issue that precluded his ability to tolerate the pneumoperitoneum of laparoscopy. But that's not a justification for NOTES. It's ludicrous. In NOTES, the abdominal cavity is still insufflated and the operation would take longer and be more hazardous to the fake patient in question. The proper solution would likely be a good old open appendectomy.

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